Provider Demographics
NPI:1225623572
Name:STATE OF NEW YORK COMPTROLLERS OFFICE
Entity Type:Organization
Organization Name:STATE OF NEW YORK COMPTROLLERS OFFICE
Other - Org Name:STATE UNIVERSITY OF NEW YORK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTALOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-826-4911
Mailing Address - Street 1:445 LENOX RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2017
Mailing Address - Country:US
Mailing Address - Phone:718-826-4911
Mailing Address - Fax:
Practice Address - Street 1:470A CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:718-270-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7001037Medicaid